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Being John Glaser 12/18/08

December 17, 2008 News 18 Comments

The National Alliance for Health Information Technology (www.nahit.org), an organization jointly sponsored by the American Hospital Association and CHIME, held a board meeting earlier this week. The organization discussed its strategy of working with providers and others to develop and disseminate “real practices.”

Real practices refers to practices that healthcare organizations have developed to help ensure that their system implementations are efficient, effective, and provide the value anticipated by the organization when they approved the project. These practices could surround applications such as CPOE, revenue cycle, and business intelligence. These practices could address project management, clinician engagement, vendor partnerships, and CIO-Board relationships.

For several reasons, the stakes have been raised for healthcare IT investments.

Increasing reimbursement and quality improvement pressures have put commensurate increasing pressure on successful electronic health record implementations. As their strategic importance and operational criticality increases, implementations that run too long, cost too much, or don’t deliver significant organizational gain will be less tolerated.

In addition, the credit and stock market challenges mean that there will be fewer IT investments. If the organization is going to fund, for example, one investment and not four others, that one investment had better deliver the goods.

The national healthcare IT agenda forms a parallel thread to the above.

The national agenda has been very focused on adoption. The low adoption rates of CPOE and outpatient electronic medical records have led to this agenda. But increasingly, it is understood that this focus is too narrow. Adoption isn’t the point. Effective use, improved care, and reduced costs of care are the point.

Hence the national agenda is evolving to augment adoption directed initiatives, e.g., financial incentives to implement an EHR, with initiatives directed to helping providers improve care using the technology.

These two threads converge to a materially heightened emphasis on execution.

Whether or not an organization is successful in implementing an application and realizing value is dependent on the vendor and implementation partner chosen. However, success is much more dependent on the organization’s skill in managing the implementation and realization of gain.

This skill can be greatly enhanced if a healthcare organization understands the “real practices” that other organizations have successfully used.

Sharing best practices is not a new idea. Association conferences are designed to share lessons learned. The value of consultants is often the experiences they bring from other organizations.

And while it is not a new idea, it is an idea that is becoming significantly more important. We might have gotten by with sub-optimal implementations in the past. We won’t be able to get by with them in the years ahead.


John Glaser is vice president and CIO at Partners HealthCare System. He describes himself as an "irregular regular contributor" to HIStalk.

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Currently there are "18 comments" on this Article:

  1. I agree with your position. NAHIT, AHA and CHIME are definitely on the right track calling for “real practices.” We should expect some insights from front-line practioners to help us gain greater use of HIT.

    One area where we need the greatest insights is change management, i.e., structured transformation of human behavior from a current to a new state. There are industry standards and real practices for HIT project and product management, but few exist for HIT change management.

  2. Without question we must move from “IT Projects” to goal oriented process redesign, and become leaders in change management in order to drive organizational efficiencies.

    Turning on hardware and software is just not going to cut it…although it may qualify your organization for a grant. 🙂

    Dr. Glaser is a great read usually, but this post was NOT funny…important…but just not funny.

  3. From MM: “Re: EMR. $83 million for an EMR?

    All that noise about handing it over to an EMR Vendor like Epic. Rubbish.

    Here’s what really happens: The vendor gets a chunk of that for software license, but that’s a fraction of the total. The bulk of the rest pays for people. (People like most of you reading this silly blog :))

    If the organization doing the project is smart, they do it with employees as much as possible. If not, then some consultants. And yes, some vendor staff.

    Putting money into Healthcare automation is probably not such a bad idea right now. Does it help a vendor – yes – so they hire people. Does it help the employees in your IT shop – yes – they are needed and don’t get laid off. Does it help the patients you serve – yes – they get better quality and service if the project is done well. Does it help the organization buying the EMR – yes – they can create efficiencies to do more with less.

    The nature of government public works projects aligns well (IMHO) with money for HC automation. I hear numbers quoted like 60 or 70 % of all health care is paid for with tax dollars (Medicare, Medicaid, Govt workers – local/state/federal, veterans, teachers, and now maybe autoworkers). If automation brings the kinds of results that a Cleveland Clinic brags about, then it may very well be in the public interest (tax payer best interest) to have some of tax money directed there to not only bring automation, but to bring good jobs to people like your readers in the course of getting the job done.

    If there is stimulus money to be spent, let’s spend it on something that makes a lasting difference. This could do that.

    And, heck, it even helps create opportunities for those people who slam vendors and EMR projects in blogs. We can all get behind supporting Mr HIStalk indirectly with some stimulus money 🙂

    Oh, and by the way – Software as a Service isn’t any cheaper than buying software and running it yourself once you reach a reasonable scale – which isn’t even that large. If you’re tiny, you will save in signing up with an ASP or the hospital next door. If you’re big though, just rough out your estimate at something close to What it Costs You + 30% (the SAS providers profit). Slice it how you want, those guys aren’t operating as charitable foundations either, although it’s a nice marketing diversion for those less gifted in the mathematical arts.

  4. GetItRight:

    You totally missed the point. Or maybe I did not explain myself well enough.

    There are other conceptual models for an EMR OTHER THAN the CDR-centric model used by most every vendor. These new moels are less complex and thus less to build and maintain.

    There are pockets of innovation out there if you look for it. A good example is the work being done at MD Anderson Cancer Center by Chuck Suitor and Kevin McEnery. They have developed a virtual database EMR that is an order of magnitude (almost) less than a commercial system. And the physicians love it.

    I am building a virtual database EMR with a twist using a Clinical Data Directory to solve an issue related to using a virtual database EMR. Anyone else out there working on innovate EMR conceptual models?

  5. GetItRight:

    I should have added that Suitor’s EMR conceptual model is a SOA, virtual database (VDB) model; the first in the country that I know about.

    And the model I’m working on is a SOA, VDB, CDD (clinical data directory) EMR.

    By the way, Chuck is one of the most innovative people in healthcare IT.

  6. So, you’ll have to buy one or more EMRs and then either get volunteers or buy (from you?) a virtual database EMR over top of it? How is that cheaper?

    Feels like Wall Street thinking – If I move the shells fast enough, can I get away with out people realizing there is no pea under any of them?

  7. Oh, and if your real argument just boils down to “build your own EMR”, the jury is back on that issue. Yes you can, it’s just really expensive. More expensive than a vendor. It takes huge sustained effort to build and maintain an EMR and to keep it advancing as vendors do inorder to compete.

    That’s why IMH, Partners, Vandy, and others have been starting to make the move. Sure, there are a few good hold outs out there to reference, MD Anderson, Marshfield, etc.

  8. Thanks. I’m just looking to explore ideas with others.

    I don’t have an argument. I do think there are some innovative new models being explored in organizations.

    The CDR-centric model is predominant in the market. It does have some signifcant drawbacks, one being duplicating data already in electronic form. The cost of a CDR is not insignificant when you count the cost of building and maintaining the CDR, the mirrored back-up since it is a “single point of failure”, and, in some cases, a “hot site” CDR.

    The virtual database model gets data from ancillary systems when required and displays them to the user as if they all came from a single system. SOA greatly simplifies building and maintaining those pipes to ancillary data.

    A clinical data directory can be thought of as a “phone book” of clinical data. It holds what is available and where it is located. That way a summary view of data does not require a request from the ancillary system. Only when a user selects an entry does the ancillary system get accessed. This reduces the load on ancillary systems.

  9. I do think though that in your virtual model, you have to still account for the new EMR data that doesn’t already have a home. There’s tons of data in an EMR that doesn’t already exist in any system. So you’d need to build something for that.

    In theory you could pull the lab results from a lab system. I could see that. You’d need to beef up the lab system to handle the volumes quite a bit. But I think you’d struggle mightily with scalability trying to do the remote procedure calls / object accesses over a network and would eventually have to cache the data locally in order to support a large scale physician and nurse user community.

    In practice, I think you’d find that trying to do this model would lead to more cost and difficulties that it sounds like on the surface. You’d really need to build out an awfully advanced cache or you’d struggle with decision support and other intense things like adhoc flowsheets and trending in real time.

  10. This model has already been proven at MD Anderson with peak loads of 5,000 simultaneous users. The economics of this model has been proven as the cost of this system was “around” an order of magnitude LESS than numbers coming from Epic for an implementation.

    As far as storing “new” EMR data the model supports that too. Any system can be integrated by simply building a service to listen for requests on the data store and building new services to go get the data. It’s really pretty simple.

    You are correct about heavy loads on ancillary systems. It is an issue with the pure virtual database model as implemented at MD Anderson. They solved it by upgrading the ancillary hardware.

    I solved it by introducing the concept of a clinical data directory. I can expand on that topic if you are interested.

  11. Again though, you have to do the All In Costs. How many staff do they have doing everything there. I’ve seen some significant numbers.

    Also the Epic numbers in your example are for EVERYTHING, not just an Epic EMR. They include the Hardware – Servers, Backup Servers, Reporting Servers, maybe Citrix plus thin clients or thick workstations, Microsoft licenses, the interfaces, connecting to patient monitors and streaming all that new data somewhere etc. Plus all the staff the customer is going to use on the project, any Epic installers, any consultants, etc. Plus any content they buy from third parties, any tools (Business Objects) that they don’t already have, etc.

    You just have to do an All In number.

    My bet is that over a comparable time period, when you add up everything that goes behind that Epic number and compare it to what MD Anderson spent on all its comparable items you’d likely find they spent even more. You can’t pick and choose which costs. You have to do an real comparative number.

  12. Counting all those costs it cost less. Why is that so hard to believe? I mean you can buy a lot of hardware and staff for the kind of money you spend on Epic and annual maintenance.

    Actually I’d prefer to discuss the pros and cons of the virtual database conceptual model versus the CDR-centric conceptual model. Can we agree they are both viable?

  13. My institution has used SOA in lieu of a CDR, mostly for cost reasons, and there are some significant pluses but also minuses to the approach.

    Some big pluses include: being in control of your own destiny (mostly) with regard to changing systems on the backend, centralized security and auditing of data access is easier, easier to bring new systems online because the data definitions are more clear and easier to understand, and the process of implementing SOA had a beneficial transformative effect on our IT silos, which are now significantly less silo’ed.

    The hard parts, though, were: defining what your SOA is (SOA governance), achieving consistent performance across a dozen different vendor systems (with different contracts, different life cycles, etc.), and getting the vendors to go along with the idea at all since most are totally ignorant (although they’ll talk about in their marketing stuff ad nauseam). Due to our environment, we do have some systems in a CDR because the vendor just couldn’t cope. We are also making an “operational data store”, which is essentially a cache of heavily used clinical data, to enable some really high performance data access systems that our basic system just can’t handle without incurring significant expense.

    Cost-wise, we wound up cheaper with the SOA, particularly over time, but the calculation is highly institution- and environment-dependent. We started in a best-of-breed place with a good dev shop, so we were in a prime position. Somebody trying to do it at an outsourced Epic shop should have his/her head examined.

    If the vendors were on board with this concept, it would be pretty easy, but unfortunately most just aren’t, and the rest are just paying lip service to it.

  14. Good comments Dr. M. Is that Dr. M as in Dr. McE?

    You are right. The challenge is to implement web services without much help from vendors. But that challange is what makes it interesting (fun).

  15. So. Let’s see. MD Anderson has 100 folks (internal and external) working for past 4 years, at $10M/yr burn rate on the SOA based EMR. Very slick viewer into clinical results but – No CPOE, little decision support, little workflow, no meds ordering other than e-routing of a form to pharmacy, no interface of drugs ordered to Rx system, no e-Mar. No doubt they will probably achieve all eventually. But another likely 4 years at this rate brings them within striking distance of EPIC. And like all home grown systems, who will support it when the key architects leave.

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